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«About your first appointment Please arrive approximately 10 to 15 minutes early for your first appointment. You may wish to arrive even earlier in ...»

Welcome to Tallahassee Eye Center

About Tallahassee Eye Center

We at the Tallahassee Eye Center are committed to providing the highest level of professional, technologically-advanced eye

health care possible through the ongoing education of our patients, our staff and our doctors, while maintaining our personal,

"family practice" attention to each patient. We take the time to get to know our patients and feel strongly that a good doctorpatient relationship improves the overall quality of health care. When you feel at ease in our office, you will be more comfortable asking questions or offering suggestions. You can relax knowing that you've chosen eye care professionals with a sincere interest in your eye health. Our simple goal is to provide modern, professional eye health care, high quality eye wear, and safe, comfortable contact lens wear. We want to help you and your family enjoy a lifetime of good vision.

About your first appointment Please arrive approximately 10 to 15 minutes early for your first appointment. You may wish to arrive even earlier in order to select a new frame prior to your examination. All of the required paperwork is available on our web site at www.TallahasseeEyeCenter.com if you prefer to complete it in advance. Please allow for approximately 1 to 1 ½ hours for your first examination.

Please bring the following:

Any glasses you currently use (clear glasses, sunglasses, reading glasses, computer glasses, etc.) • Your current contact lenses (including the boxes). You may wear your lenses to the examination if desired.

• Your medical history including current medications and dosages.

• Your insurance card, if applicable (medical and vision discount plan) • A note about dilation The doctors at Tallahassee Eye Center routinely dilate the pupils of the eyes in order to obtain a thorough dilation

on:

view of the interior structures of the eye. Without pupil dilation, the doctor will not be able to completely evaluate your eye health and may not detect certain diseases and disorders. Pupil dilation usually results in blurry near vision and increased light sensitivity for 3 to 6 hours. Although most patients have minimal effect upon their distance vision and feel comfortable driving after dilation, it is possible that you may not see well enough to drive safely. It is your responsibility to make arrangements to be transported by other means if you feel that your vision is too blurry to drive safely following dilation. It is also your responsibility to notify the doctor and staff if you do not wish to have your eyes dilated or would prefer to reschedule the dilation.

Office Hours: Contact Us:

Us:

Monday through Thursday: 8:00am to 5:00pm Tele

–  –  –

Eye examinations for adults and children • Contact lens evaluations and fittings (including those patients who have been told by other doctors that they are • “difficult” to fit). Our doctors also serve as clinical investigators for most major contact lens manufacturers and are involved with the development of new products.

Treatment and management of ocular disease, including cataracts, glaucoma, macular degeneration, diabetic • retinopathy, conjunctivitis (“pinkeye”), dry eye syndrome, ocular allergies, removal of foreign bodies and more. We also co-manage most ocular surgeries.

Low vision care (for patients who are visually impaired) • We also have a full-service optical department to meet all of your eyewear needs.

• Our Optical Department Purchasing a quality pair of glasses is not an easy decision. With current technology, the options are seemingly endless. That's where we can help. Tallahassee Eye Center offers a full service optical dispensary with a wide variety of high-quality frames to choose from. In addition, we offer all the latest lens material and lens options, including high index plastic, anti-reflective coating, photochromics (Transitions), computer lenses, and the most technologically advanced progressive lenses available. Our optical experts will consider your eyeglass prescription, occupation, and recreational activities in order to help determine which options will best suit your needs. Our optical department is managed by Paul Wilford, a licensed dispensing optician, with nearly 30 years of experience.

Our Contact Lens Department As contact lens specialists, the doctors at Tallahassee Eye Center fit contact lenses of all types, including tinted lenses, disposable daily wear lenses, lenses for astigmatism, and bifocal. We also offer Vision Shaping Treatment (ortho-keratology) for the reduction or elimination of near-sightedness while you sleep. If you have questions about whether or not you would be a good candidate for contact lenses, please be sure to ask.

About Your Insurance There are two types of benefits that may help pay for your eye care services and/or products. Our practice is a provider for most vision discount plans and medical insurance plans. You may be covered by either, both, or neither of these plans.

Vision discount plans (such as VSP, Humana Comp Benefits and EyeMed) - Vision discount plans typically cover • routine vision exams and provide an allowance or discount toward the purchase of eyeglasses or contact lenses.





Vision plans only cover a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases.

Medical insurance (such as Blue Cross/Blue Shield and Medicare) - Medical insurance must be used if you have any • eye health problem or systemic health problem that has ocular complications. Your doctor will determine if these conditions apply to you, but some are determined by your case history.

If you have both types of benefits, it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense. We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract.

TALLAHASSEE EYE CENTER

PATIENT INFORMATION Date: ________________

–  –  –

Occupation: ____________________________________________ Employer: __________________________________

Spouse’s Name: ______________________ Dependent Children’s Name(s):___________________________________

Person to contact in case of emergency: _______________________________________ Phone: ___________________

How did you hear about our office?______________________________________________________________________

INSURANCE INFORMATION (please bring all insurance cards to receptionist) Primary Medical Insurance: ________________________________ Secondary Medical Insurance: ____________________

Vision Insurance: ________________________________________

AUTHORIZATIONS

Please list the names of any individuals with whom you give us permission to share your medical information (family, caretakers, etc.):

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

I acknowledge that I have received a copy of Tallahassee Eye Center’s Notice of Privacy Practices.

Patient Signature: _________________________________________________ Date: _____________________

I authorize the release of any medical information necessary to process insurance claims to my insurance company and/or any other physician or health care provider that may be involved in my care. I authorize and request my insurance company to remit payment of benefits directly to Tallahassee Eye Center. I further understand that I am responsible for payment for all services rendered including those services that may not be covered by my insurance company. This authorization is to be valid until otherwise revoked in writing.

Patient Signature: _________________________________________________ Date: _____________________

The doctors at Tallahassee Eye Center routinely dilate the pupils of the eyes in order to obtain a thorough view of the interior structures of the eye. Without pupil dilation, the doctor will not be able to completely evaluate your eye health and may not detect certain diseases and disorders. Pupil dilation usually results in blurry near vision and increased light sensitivity for 3 to 6 hours. Although most patients have minimal effect upon their distance vision and feel comfortable driving after dilation, it is possible that you may not see well enough to drive safely. It is your responsibility to make arrangements to be transported by other means if you feel that your vision is too blurry to drive safely following dilation. It is also your responsibility to notify the doctor and staff if you do not wish to have your eyes dilated or would prefer to reschedule the dilation.

I have read and understand the above statement regarding pupil dilation.

Patient Signature: __________________________________________________ Date: _______________________

MEDICARE

♦COVERAGE OVERVIEW

For your convenience, our office is a participating provider with Medicare. This means that our office bills Medicare for your office visits, tests and materials. Medicare then reviews all submitted claims and if approved, reimburses our office 80% of the approved amount. The remaining 20% (the co-payment) is your responsibility as the Medicare beneficiary.

You are also responsible for a deductible and certain non-covered fees, as described below. Our office may elect to 1) bill you directly for your portion of the fees, or 2) bill your supplemental insurance, if you carry it.

♦MEDICARE HMO PLANS

Tallahassee Eye Center is not a provider for any Medicare HMO plans (Advantage Plus, Universal, CHP Medicare, etc.).

If you are a participant with any of these plans, you will be responsible for payment for your services and materials. We will be happy to provide you with the paperwork you will need to supply your insurance company for any appropriate reimbursement.

♦DEDUCTIBLE Medicare has a yearly deductible that takes effect each January and may change from year to year. If our office is the first to submit a Medicare claim for you in the current calendar year, Medicare will notify you that you have not met your deductible for the year. Medicare will not pay for your allowable fees until the deductible is met.

♦EXCEPTIONS, NON-COVERED SERVICES & MATERIAL FEES

Medicare does not pay for refractive services. This is the part of your eye exam that determines your prescription ♦ for eyeglasses. It is typically performed on a yearly basis.

Medicare will not pay for any services unless there is a medical reason for the visit. Preventative medical ♦ services and screenings are not covered by Medicare. If your exam is purely “routine” (to determine your eyeglasses prescription and screen for eye disease) and no separate medical diagnosis is made, Medicare will not cover any fees for that visit.

Medicare does not cover glasses or contact lenses unless you have had cataract surgery. If you have had ♦ cataract surgery, Medicare will cover a portion of the cost of your eyeglass lenses and one standard frame one time per operation. Any additional lens options or frame upgrades are your responsibility.

♦AUTHORIZATION STATEMENT/SIGNATURE

I have read and understand the information above and agree to pay for any services and materials I order, but which are not covered by Medicare.

Patient/Beneficiary Signature________________________________________________ Date__________________

♦LIFETIME INSURANCE SIGNATURE ON FILE

I certify that the information given by me in applying for the insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits, and I authorize payment of these benefits directly to Tallahassee Eye Center on my behalf for any services and materials furnished. I authorize and holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage (as indicated in Item 9 of the HCFA-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer or agency shown, and authorizes my doctor to act as my agent, as above.



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